The purpose of a SAR is to identify learning and improvement actions which prevent future deaths or serious harm occuring again,  This includes where the review can provide useful insights into the way organisations are working together to prevent or reduce the abuse or neglect of adults at risk.

SARs are not enquiries into how an adult at risk died or who is culpable. SARs are an opportunity to consider how agencies worked together, to share lessons learnt so that we can further improve the way we work together with adults at risk of abuse or neglect.

SARs are also a useful mechanism to explore examples of good practice where this is likely to identify lessons which could be applied to future practice or cases.

Senior Managers or Safeguarding Leaders are selected to represent organisations who worked with the adult, as a SAR Panel member. 

The role of Panel members is to provide senior oversight, ensuring the review is thorough, accountable, and leads to real improvements in safeguarding practice.

Core responsibilities are to:

• Oversee the review process, including agreeing scope and ensuring statutory compliance.
• Analyse information and challenge practice to identify learning and shape meaningful recommendations.
• Represent organisations at a senior level, ensuring communication, engagement, and governance.
• Promote and embed learning across agencies, turning recommendations into measurable improvement and action.
• Maintain strategic accountability by reporting progress to the Safeguarding Adults Board.

In line with statutory guidance, practitioners should be involved in the statutory review process and are invited to contribute their views or perspectives of practice and the wider system. 

Practitioner Learning Events (PLEs) are facilitated by an Independent Reviewer commissioned to deliver the SAR process.  The Independent Reviewer is independent of all agencies involved in the SAR process. 

The key aim of the PLE is to collaborate with all practitioners from the agencies who knew the adult and their family providing the time and safe space to reflect on thier involvement, professional practice and decision making at the time.

The information collated at the event enables the SAR Reviewer to understand in greater depth whether there are any lessons that can be learnt to improve practice in the future and it also enables good practice to be identified and shared.

In a safe space the Independent Reviewer will also explore barriers in the system for practitioners to identify wider systems learning.

The Practitioner Learning Event WILL:

• Hear your first-hand accounts of involvement with the adult and their family.
• Provide an opportunity to ensure the accuracy of the case ‘story’ gathered through chronologies and agency reports.
• Provide an opportunity to consider and analyse interventions in a safe, non blaming and reflective environment.
• Consider the context within which practitioners were working at the time.
• Explore what information, activity, barriers or circumstances might have influenced decision making at the time.
• Consider and contribute to the recommendations for the SAR.
• Provide an opportunity for practitioners to shape future policy, practice and system learning.

The Practitioner Learning Event WILL NOT: 

• Attempt to apportion blame.
• Single out individual practitioners.
• Be critical of specific agencies.

It is important to stress that the review process is not designed to apportion blame, but to try and understand what happened and the wide range of factors or barriers that affected the way people responded to the circumstances of the case at the time and will also identify good practice.

If you are asked to attend a PLE, you will be provided with support by Managers and SAR Panel members in advance, on the day and following the event.  

The Safeguarding Adults Board will also engage with the adult, family or carers of the adult to contribute to the review process. 

Families are often in a position to really help us understand what it is agencies need to do better so that future professional practice is able to improve. The decision for families to take part in a review is optional and where families do not feel able to contribute this is respected.  Families will be informed when a review is nearing completion so learning can be shared ahead of publication of a report.

SAR reports provide an analysis of what happened, why and what action needs to be taken to prevent reoccurence.

In the interests of transparency and dissemination of learning most SARs are published in line with statutory guidance and best practice.  SAR reports will not attribute any identifiable actions and focus on systems learning.  Equally pseudonyms are used for the adult involved, unless the individual or family express they wish to use real names.  

You can read CSAB's published SARs including the learning and recommendations here.

You will also find recordings of SAR lunch & learn sessions delivered to share learning from SARs with wider practitioners across the system.  These sessions can be used for continuing professional development (CPD) purposes.